老年患者髓外脊髓肿瘤手术中多模态术中神经生理监测的可行性。
Feasibility of multimodal intraoperative neurophysiological monitoring for extramedullary spinal cord tumor surgery in elderly patients.
机构信息
Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
出版信息
Acta Neurochir (Wien). 2023 Aug;165(8):2089-2099. doi: 10.1007/s00701-023-05682-8. Epub 2023 Jun 24.
BACKGROUND/PURPOSE: Extramedullary spinal cord tumors (EMSCTs) are mostly benign tumors which are increasingly diagnosed and operatively treated in the elderly. While there are hints that multimodal intraoperative neurophysiological monitoring (IONM) could be influenced by age and age-related comorbidities, no study has ever systematically evaluated its feasibility and value for EMSCT surgery in elderly patients.
METHODS
We retrospectively evaluated all patients with microsurgical EMSCT resection under continuous multimodal IONM with SSEPs, MEPs and electromyography between 2016 and 2020. Epidemiological, clinical, imaging and operative/IONM records as well as detailed individual outcomes were analyzed and compared for the cohort < / ≥ 65 years.
RESULTS
Mean age was 45 years in cohort < 65 years (n = 109) and 76 years in cohort ≥ 65 years (n = 64), while baseline/operative characteristics did not significantly differ. Mean baseline SSEPs' latencies (left-right average) were significantly higher in the cohort ≥ 65 years for both median (20.9 ms vs. 22.1 ms; p < 0.01) and tibial nerve (42.9 ms vs. 46.1 ms; p < 0.01) without significant differences for SSEPs' amplitudes. Stimulation intensity to elicit intraoperative MEPs was significantly higher in the cohort ≥ 65 years (surrogate-marker: left-right-averaged quotient ID1-muscle/abductor-hallucis-muscle; 1.6 vs. 2.1; p < 0.001). Intraoperatively, SSEP and MEP monitoring were feasible in 99%/100% and 99%/98% for the cohort < / ≥ 65 years without significant differences in rates for significant IONM changes during surgery or postoperatively new sensorimotor deficits. Sensitivity of IONM was 29%/43%, specificity 99%/98%, positive and negative predictive values 67%/75% and 95%/93% for the cohort < / ≥ 65 years. Overall, age was no risk factor for IONM feasibility or rate of significant IONM changes.
DISCUSSION
Multimodal IONM is feasible/reliable for EMSCT surgery in elderly patients. An age-related prolongation of SSEPs' latencies and demand for higher stimulation intensities for MEPs' elicitation has to be considered.
背景/目的：髓外脊髓肿瘤（EMSCT）多为良性肿瘤，在老年人中的诊断和手术治疗日益增多。虽然有迹象表明，多模态术中神经生理监测（IONM）可能受到年龄和与年龄相关的合并症的影响，但尚无研究系统评估其在老年患者 EMSCT 手术中的可行性和价值。
方法
我们回顾性评估了 2016 年至 2020 年间在连续多模态 IONM 下进行的显微 EMSCT 切除术的所有患者，监测 SSEP、MEP 和肌电图。对年龄 <65 岁（n=109）和年龄≥65 岁（n=64）的队列进行了流行病学、临床、影像学和手术/IONM 记录以及详细的个体结果分析和比较。
结果
年龄<65 岁的队列平均年龄为 45 岁，年龄≥65 岁的队列平均年龄为 76 岁，而基线/手术特征无显著差异。在年龄≥65 岁的队列中，双侧正中神经 SSEP 潜伏期（20.9ms 对 22.1ms；p<0.01）和双侧胫神经 SSEP 潜伏期（42.9ms 对 46.1ms；p<0.01）均显著延长，而 SSEP 振幅无显著差异。年龄≥65 岁的队列中，诱发电位的刺激强度明显更高（替代标志物：左右平均比值 ID1-肌肉/外展肌-趾屈肌；1.6 对 2.1；p<0.001）。术中 SSEP 和 MEP 监测在年龄<65 岁和年龄≥65 岁的患者中分别为 99%/100%和 99%/98%，术中或术后新的感觉运动缺陷的 IONM 显著变化发生率无显著差异。IONM 的敏感性为 29%/43%，特异性为 99%/98%，阳性和阴性预测值分别为 67%/75%和 95%/93%，年龄<65 岁和年龄≥65 岁的患者均如此。总体而言，年龄不是 IONM 可行性或 IONM 显著变化发生率的危险因素。
讨论
多模态 IONM 可用于老年患者的 EMSCT 手术，可靠。必须考虑 SSEP 潜伏期的年龄相关性延长和 MEPs 诱发所需的更高刺激强度。
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